Form 241 Report of Proposed Activities in Non-Agreement States Ar

NRC FORM 241

U.S. NUCLEAR REGULATORY COMMISSION

(MM-YYYY)

REPORT OF PROPOSED ACTIVITIES IN NON-AGREEMENT
STATES, AREAS OF EXCLUSIVE
FEDERAL JURISDICTION, OR OFFSHORE WATERS
(Please read the instructions before completing this form)

APPROVED BY OMB: NO. 3150-0013

EXPIRES: (MM/DD/YYYY)

Estimated burden per response to comply with this mandatory collection request: 30 minutes. This notification
is required so that NRC may schedule inspection of the activities to ensure that they are conducted in
accordance with requirements for protection of the public health and safety. Send comments regarding burden
estimate to the Information Services Branch (T-2 F43), U. S. Nuclear Regulatory Commission, Washington, DC
20555-0001, or by e-mail to [email protected], and to the Desk Officer, Office of Information and
Regulatory Affairs, NEOB-10202, (3150-0013), Office of Management and Budget, Washington, DC 20503.
If a means used to impose an information collection does not display a currently valid OMB control number, the
NRC may not conduct or sponsor, and a person is not required to respond to, the information collection.
2. TYPE OF REPORT

1. NAME OF LICENSEE (Person or firm proposing to conduct the activities described below)

INITIAL
3. ADDRESS OF LICENSEE (Mailing address or other location where licensee may be located)

CHANGE

4. LICENSEE CONTACT AND TITLE

5. OFFICE NUMBER

5a. WORK CELL NUMBER

6. FACSIMILE NUMBER

7. E-MAIL ADDRESS

8. ACTIVITIES TO BE CONDUCTED UNDER THE GENERAL LICENSE GIVEN IN 10 CFR 150.20

WELL LOGGING

LEAK TESTING AND/OR CALIBRATIONS

PORTABLE GAUGES

OTHER (Specify)

TYPE OF SERVICE

REGISTERED AS USER OF PACKAGING (Certificates of Compliance Numbers)

RADIOGRAPHY
10. ACTUAL PHYSICAL ADDRESS OF WORK LOCATION
(Street and Number or other location. Provide GPS Coordinates if known.)

9. CLIENT NAME, ADDRESS, CITY/COUNTY, STATE, ZIP CODE

11. CLIENT TELEPHONE NUMBER
OFFICE

13. DATES SCHEDULED
FROM

TO

14. NUMBER OF
WORK DAYS

WEEKENDS

Yes

12. WORK LOCATION TELEPHONE NUMBER

WORK CELL

15. ADD

OFFICE

16. DELETE

WORK CELL

17. LOCATION REFERENCE NO. (Assigned by NRC)

No

LIST ADDITIONAL WORK SITES ON SEPARATE SHEET(S) TO INCLUDE ALL INFORMATION IN ITEMS 10-17 ABOVE.
18. LIST RADIOACTIVE MATERIAL THAT WILL BE POSSESSED, USED, INSTALLED, SERVICED, OR TESTED.
(Include description of type and quantity of radioactive material, sealed sources, or devices to be used.)

DEVICE TYPE / SEALED SOURCES

19. AGREEMENT STATE SPECIFIC LICENSE WHICH AUTHORIZES THE UNDERSIGNED TO CONDUCT ACTIVITIES
WHICH ARE THE SAME, EXCEPT FOR LOCATION OF USE, AS SPECIFIED IN ITEM 10 ABOVE.
(One copy of the specific license must accompany the initial NRC Form 241.)

LICENSE NUMBER

MODEL NUMBER

STATE

EXPIRATION DATE

20. CERTIFICATION (MUST BE COMPLETED BY APPLICANT)
I, THE UNDERSIGNED, HEREBY CERTIFY THAT:
a. All information in this report is true and complete.
b. I have read and understand the provision of the general license 10 CFR 150.20 reprinted on the instructions of this form; and I understand that I am required to comply with these
provisions as to all byproduct, source, or special nuclear material which I possess and use in non-Agreement States or offshore waters under the general license for which this
report is filed with the U. S. Nuclear Regulatory Commission.
c. I understand that activities, including storage, conducted in non-Agreement States under general license 10 CFR 150.20 are limited to a total of 180 days in calendar year. With the
exception of work conducted in off-shore waters, which is authorized for an unlimited period of time in the calendar year.
d. I understand that I may be inspected by NRC at the above listed work site locations and at the Licensee home office address for activities performed in non-Agreement States or
offshore waters.
e. I understand that conduct of any activities not described above, including conduct of activities on dates or locations different from those described above or without NRC
authorization, may subject me to enforcement action, including civil or criminal penalties.
APPROVED BY RSO OR MANAGEMENT REPRESENTATIVE (Printed Name and Title)

SIGNATURE

DATE

TOTAL USAGE - DAYS TO DATE

WARNING: False statements in this certificate may be subject to civil and/or criminal penalties. NRC regulations require that submissions to the NRC be complete and accurate in all material respects.
18 U.S.C. Section 1001 makes it a criminal offense to make a willfully false statement or representation to any department or agency of the United States as to any matter within its jurisdiction.

APPROVED BY (Typed/Printed Name and Title)

FOR NRC
USE ONLY

NON-PUBLIC

NRC FORM 241 (MM-YYYY)

SIGNATURE

SENSITIVE-SECURITY RELATED MD 3.4 NON-PUBLIC a.3

DATE

TOTAL USAGE - DAYS TO DATE

ADAMS ML #

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APPROVED BY OMB: NO. 3150-0013
EXPIRES: (MM/DD/YYYY)

NRC FORM 241
(MM-YYYY)

U.S. NUCLEAR REGULATORY COMMISSION
EXCLUSIVE FEDERAL JURISDICTION, OR OFFSHORE WATERS
PLEASE READ THIS INFORMATION AND THESE INSTRUCTIONS BEFORE COMPLETING NRC FORM 241
Section 150.20 of 10 CFR 150 establishes a general license authorizing any person who holds a specific license from an "Agreement
State" (a State with which the U.S. Nuclear Regulatory Commission has entered into an effective agreement under subsection 274b of the
Atomic Energy Act of 1954) where the licensee maintains an office for directing the licensed activity and at which radiation safety records
are normally maintained, to conduct the same activity in Non-Agreement States, areas of exclusive Federal jurisdiction, or in offshore
waters if the specific license issued by the Agreement State does not limit the authorized activity to specified locations or installations.

INSTRUCTIONS
Licensees cannot perform work in areas of exclusive Federal jurisdiction without either (a) filing NRC Form 241 for reciprocity in
accordance with 10 CFR 150.20(b) or (b) applying for a specific NRC license. An area of exclusive Federal jurisdiction is an area over
which the Federal government exercises legal control without interference from the jurisdiction and administration of State law. For
example: If the work is to be performed on Federal property in an Agreement State, the licensee must first determine the jurisdictional
status of the area where the licensee plans to work. If the jurisdictional status of the work site is unknown to the licensee, the Agreement
State licensee should contact the Federal agency that controls the facility where the work is to be performed. A written statement
concerning the jurisdictional status is not required in order to file for reciprocity; however, it is recommended that the Agreement State
licensee obtain such a statement for the file for future reference and inspection purposes.
For licensees seeking to conduct activities under reciprocity for the first time in a calendar year, submit this Form, one copy of the
Agreement State specific license and the fee specified in fee Category 16, 10 CFR 170.31. NRC must receive this filing at least 3 days
before the licensee engages in activities permitted under the General License established by Section 150.20 of 10 CFR 150.
In general, the preferred method of filing is through the facsimile transmission of NRC Form 241, a copy of the Agreement State license,
and evidence that the appropriate fee requirements will be met within 3 days. This evidence can be a copy of the check or a copy of NRC
Form 629, if paying by credit card, that will be mailed to the NRC. The licensee should receive confirmation (by telephone, e-mail, or
facsimile) that NRC has received the facsimile. Alternatively, the licensee may file the required information through the mail or other means
as long as NRC receives the information at least 3 days before the licensee engages in the activity.
In completing NRC Form 241, it is important that the information submitted on NRC Form 241 be specific regarding the location and date of
use as well as the activity requested. If it is not possible to provide complete information, such as addresses for the locations of work, the
licensee should contact the appropriate Regional Office to discuss proposed work activities. The licensee is responsible for providing
additional information as revisions or clarifications as soon as such information becomes available.
Item 2.
For licensees seeking to conduct activities under reciprocity for the first time in a calendar year, submit this Form, one copy of the
Agreement State specific license and the fee specified in fee Category 16, 10 CFR 170.31. NRC must receive this filing at least 3 days
before the licensee engages in activities permitted under the General License established by Section 150.20 of 10 CFR 150. The licensee
should check the "initial" box if this is the first submission of NRC Form 241 for the year.
For modification such as the information submitted on the initial NRC Form 241, such as additional work locations, changes to radioactive
material, work activities, information that clarifies or deletes specific locations, or work sites, work site contacts, or adds or deletes dates of
work, licensees should file by NRC Form 241 or letter, so that NRC receives the filing at least 3 days prior to engage in such activity.
Licensees should check the "change" box to indicate changes to the information provided on the initial NRC Form 241. It is not necessary
to resubmit the Agreement State license unless the license has been amended since the filing of the initial NRC Form 241. No fee is
required for changes. NRC Form 241 may be used for submitting multiple work locations and clients for initial filings of NRC Form 241, as
well as for submitting changes to previous filings. Separate sheets maybe used provided it includes all of the requested information in
Items 10-17 of NRC Form 241.
Under the general license, reciprocity activities are authorized only as long as the licensee holds a valid radioactive material license. If the
license expires during the year, an extension letter or a renewed license issued by the regulating agency must be submitted to NRC before
performing any additional work under reciprocity.
Item 8.
Licensees should be advised that the documents containing sensitive information must be marked and protected in accordance with any
applicable security requirements. This applies to information transmitted to and from the NRC as well as maintained for record keeping
purposes.
Item 10.
Licensees should provide driving directions for locations of work without physical addresses or in remote locations. If known, licensees
should include Global Positioning System (GPS) coordinates.
NRC FORM 241 (MM-YYYY)

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APPROVED BY OMB: NO. 3150-0013
EXPIRES: (MM/DD/YYYY)

NRC FORM 241
(MM-YYYY)

U.S. NUCLEAR REGULATORY COMMISSION
EXCLUSIVE FEDERAL JURISDICTION, OR OFFSHORE WATERS
INSTRUCTIONS (Continued)
Items 13. - 17.
Under the general license, reciprocity activities, including storage (usage), conducted in non-Agreement States and areas of exclusive
Federal jurisdiction, are limited to a total of 180 days in any calendar year except for work conducted in off-shore waters, which is
authorized for an unlimited period of time in a calendar year. NRC tracks reciprocity usage on the basis of approved usage days. NRC will
not approve any activity under the general license which causes the total usage days to exceed 180 days, except for work conducted in offshore waters. NRC may note and notify the licensee that a filing proposes reciprocity activities which approach or would exceed the 180day limit. It is important that licensees track the days of use and clarify or delete dates of work when applicable.
Item 13. should reference the proposed beginning and ending dates of work for each work location, and indicate if work will be performed
on weekends, with the total number of days worked recorded in Item 14. Item 15. should be completed to show additional work dates
different from those provided on the initial NRC Form 241 and Item 16. should indicate dates when work was not performed, as initially
requested, that need to be deleted from the total work days. The Location Reference Number in Item 17. is generated by the NRC for use
in tracking reciprocity activities and is specific for each work location. The Location Reference Number should be referenced for any
changes to work location information.
Item 18.

Licensees should identify the specific make and model numbers of sealed sources and devices.

NOTE:

Inspections by NRC of activities performed in non-Agreement States, areas of exclusive Federal jurisdiction, or offshore
waters by Agreement State licensees operating under the general license in 10 CFR 150.20 will be conducted at the listed
work site location(s). Failure to file an NRC Form 241 may result in the issuance of a notice of violation, the proposed
imposition of a civil penalty, or an order suspending, modifying, or revoking the license as specified in the "General
Statement of Policy and Procedures for NRC Enforcement Actions."

Agreement State licensees seeking to conduct activities under Reciprocity should file this Form, one copy of the Agreement State
license, and the appropriate fee with the U.S. Nuclear Regulatory Commission Regional Administrator listed below for the region in
which the Agreement State that issued the specific license is located:
IF THE AGREEMENT STATE LICENSE IS ISSUED BY:

IF THE AGREEMENT STATE LICENSE IS ISSUED BY:

Alabama, Florida, Georgia, Kentucky, Maine, Maryland,
Massachusetts, New Hampshire, New Jersey, New York,
North Carolina, Pennsylvania, Rhode Island,
South Carolina, Virginia, or Tennessee

Illinois, Iowa, Minnesota, Ohio, or Wisconsin,

SEND APPLICATION AND FEE PAYMENT TO:
Regional Administrator
Division of Nuclear Material Safety
ATTN: Reciprocity Request
U.S. Nuclear Regulatory Commission, Region I
2100 Renaissance Boulevard, Suite 100
King of Prussia, PA 19406-2713
Telephone Number (800) 432-1156
Facsimile Number (610) 337-5269

SEND APPLICATION AND FEE PAYMENT TO:
Regional Administrator
Division of Nuclear Material Safety
ATTN: Reciprocity Request
U.S. Nuclear Regulatory Commission, Region III
2443 Warrenville Road, Suite 210
Lisle, IL 60532-4352
Telephone Number (630) 829-9887
Facsimile Number (630) 515-1259

IF THE AGREEMENT STATE LICENSE IS ISSUED BY:
Arizona, Arkansas, California, Colorado, Kansas,
Louisiana, Mississippi, Nebraska, Nevada, New Mexico,
North Dakota, Oklahoma, Oregon, Texas, Utah, or Washington
SEND APPLICATION AND FEE PAYMENT TO:
Regional Administrator
Division of Nuclear Material Safety
ATTN: Reciprocity Request
U.S. Nuclear Regulatory Commission, Region IV
1600 E. Lamar Boulevard
Arlington, TX 76011-4125
Telephone Number (817) 860-8100
Facsimile Number (817) 200-1188
NRC FORM 241 (MM-YYYY)

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APPROVED BY OMB: NO. 3150-0013
EXPIRES: (MM/DD/YYYY)

NRC FORM 241
(MM-YYYY)

U.S. NUCLEAR REGULATORY COMMISSION
EXCLUSIVE FEDERAL JURISDICTION, OR OFFSHORE WATERS
INSTRUCTIONS (Continued)
150.20 Recognition of Agreement State licenses
(a)(1) Provided that the provisions of paragraph (b) of this section have been met, any person who holds a specific license from an
Agreement State, where the licensee maintains an office for directing the licensed activity and retaining radiation safety records, is
granted a general license to conduct the same activity in (i) Non-Agreement States; (ii) Areas of exclusive Federal jurisdiction within
Agreement States; and (iii) Offshore waters.
(2) The provisions of paragraph (a)(1) of this section do not apply if the specific Agreement State license limits the authorized activity
to a specific installation or location.
(b) Not withstanding any provision to the contrary in any specific license issued by an Agreement State to a person engaging in
activities in a non-Agreement State, in an area of exclusive Federal jurisdiction within an Agreement State, or in offshore waters
under the general licenses provided in this section, the general licenses provided in this section are subject to all the provisions of the
Act, now or hereafter in effect, and to all applicable rules, regulations, and orders of the Commission including the provisions of §§
30.7 (a) through (f), 30.9, 30.10, 30.14(d), 30.34, 30.41, and 30.51 to 30.63, inclusive, of part 30 of this chapter; §§ 40.7 (a) through
(f), 40.9, 40.10, 40.41, 40.51, 40.61, 40.63 inclusive, 40.71 and 40.81 of part 40 of this chapter; §§ 70.7 (a) through (f), 70.9, 70.10,
70.32, 70.42, 70.52, 70.55, 70.56, 70.60 to 70.62 of part 70 of this chapter; §§ 74.11, 74.15, and 74.19 of part 74 of this chapter; and
to the provisions of 10 CFR parts 19, 20 and 71 and subparts C through H of part 34, §§ 39.15 and 39.31 through 39.77, inclusive, of
part 39 of this chapter. In addition, any person engaging in activities in non- Agreement States, in areas of exclusive Federal
jurisdiction within Agreement States, or in offshore waters under the general licenses provided in this section:
(1) Shall, at least 3 days before engaging in each activity for the first time in a calendar year, file a submittal containing an NRC Form
241, "Report of Proposed Activities in Non-Agreement States"' a copy of its Agreement State specific license, and the appropriate fee
as prescribed in § 170.31 of this chapter with the Regional Administrator of the U.S. Nuclear Regulatory Commission Regional Office
listed on the NRC Form 241 and in appendix D to part 20 of this chapter for the Region in which the Agreement State that issued the
license is located. If a submittal cannot be filed 3 days before engaging in activities under reciprocity, because of an emergency or
other reason, the Regional Administrator may waive the 3-day time requirement provided the licensee:
(i) Informs the Region by telephone, facsimile, an NRC Form 241, or a letter of initial activities or revisions to the information submitted on
the initial NRC Form 241;
(ii) Receives oral or written authorization for the activity from the Region; and
(iii) Within 3 days after the notification, files an NRC Form 241, a copy of the Agreement State license, and the fee payment.
(2) Shall file an amended NRC Form 241 or letter with the Regional Administrator to request approval for changes in work locations,
radioactive material, or work activities different from the information contained on the initial NRC Form 241.
(3) Shall not, in any non-Agreement State, in an area of exclusive Federal jurisdiction within an Agreement State, or in offshore
waters, transfer or dispose of radioactive material possessed or used under the general licenses provided in this section, except by
transfer to a person who is-(i) Specifically licensed by the Commission to receive this material; or
(ii) Exempt from the requirements for a license for material under § 30.14 of this chapter.
(4) Shall not, under the general license concerning activities in non-Agreement States or in areas of exclusive Federal jurisdiction
within Agreement States, possess or use radioactive materials, or engage in the activities authorized in paragraph (a) of this section,
for more than 180 days in any calendar year, except that the general license in paragraph (a) of this section concerning activities in
offshore waters authorizes that person to possess or use radioactive materials, or engage in the activities authorized, for an unlimited
period of time.
(5) Shall comply with all terms and conditions of the specific license issued by an Agreement State except such terms or conditions
as are contrary to the requirements of this section.
[35 FR 7725, May 20, 1970, as amended at 38 FR 1273, Jan. 11, 1973; 46 FR 44152 , Sept. 3, 1981; 46 FR 50781, Oct. 15, 1981; 52
FR 41700, Oct. 30, 1987; 55 FR 10406, Mar. 21, 1990; 56 FR 54779, Oct. 23, 1991; 58 FR 52414, Oct. 8, 1993; 62 FR 1665, Jan. 13,
1997; 62 FR 28973, May 28, 1997; 66 FR 5443, Jan. 19, 2001; 66 FR 32469, June 1 4, 2001; 67 FR 78149, Dec. 23, 2002; 68 FR
58825, Oct. 10, 2003]

NRC FORM 241 (MM-YYYY)

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